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Authorised and published by Victorian Government, 50 Lonsdale Street, Melbourne.

Transfer of care from acute inpatient services

Guidelines for managingthe transfer of care of acute inpatients from

Victoria’s public health services

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Contents

Purpose
Introduction
Principles
Planning for transfer of care
Implementing the transfer of care plan
Post transfer of care
Performance measures for transfer of care

Appendix: Suggested content for a transfer of care summary

Purpose

The purpose of these guidelines are to:

promote consistenttransfer of care practices across the Victorian public health system
support health services to review their existing discharge and transfer of care practices and to implement more effective transfer of care processes
improve communication between health services and the patient, the patient’s family and/or carer, the patient’s general practitioner (GP) and community service providers.

Health services are encouraged to develop or update their own local policies, procedures and staff education programs to align with the principles and guidelines specified in this document.

Introduction

The 2008 Victorian Auditor General’s Office report Managingacute patient flows examined the effectiveness and efficiency of patient flow in Victorian public hospitals. The report recommended that public hospitals develop comprehensive policies and procedures that clearly outline staff roles and responsibilities relating to discharge and transfer of care.

Transfer of care involves transferring professional responsibility and accountability for the care of a patient to another person or professional or a combination of professionals.[1]When a patient is discharged from an acute setting their ongoing care should be transferred to another person or team. The purpose of transfer of care is to achieve a safe, seamless journey that ensures continuity of care for the patient.

Transfer of care is part of the discharge process. Transfer of care in the context of these guidelines can occur when a patient is discharged home following their inpatient admission at which point their care is transferred to their GP, their carer, their family, a community service or an aged care facility. Transfer of care also occurs when a patient is transferred from an acute inpatient setting to subacute or non-acute care if the patient cannot return to their usual residence following their acute inpatient admission.

The transfer of care process plays an important role in enhancing patient outcomes, reducing readmissions, improving hospital efficiency and improving patient flow through health services. Developing and consistently implementing effective transfer of care and discharge processes can reduce unplanned readmissions and the length of time patients stay in hospital.

These guidelines aim to improve patient health outcomes and experiences of discharge and transfer of care from the acute inpatient hospital environment. These guidelines provide a framework for managing the transfer of care of acute inpatients from Victoria’s public health services to subacute services, community-based services (such as aged care facilities) and home.A further resource is the Australian Medical Association’s position statement General practice/hospitals transfer of care arrangements.[2]

These guidelinesare presented in three sections to reflect the key phases of transfer of care:

planning for transfer of care
implementing the transfer of care plan
posttransfer of care.

Principles

The following principles underpin these guidelines across the three phases of transfer of care.

The National safety and quality health service standards are adhered to.

In 2011 the Australian health ministers endorsed the National safety and quality health service standards. The standards were developed by the Australian Commission on Safety and Quality in Healthcare and are designed to assist health services to deliver safe and high-quality care. The guidelines in this document are inline with the standards and this document should be read in conjunction with the standards.

Patients (and their families and/or carers) are involved in decision making about their care.

An effective transfer of care strategy is collaborative and focuses on communication with the patient and their family and/or carer. Transfer of care policies, protocols and practices should be sensitive to the needs of different patient groups and individuals.

Victorian public health services have a consistent approach to transfer of care.

Standardised transfer of care protocols and criteria should be developed to promote consistency of practice across hospital wards and medical/surgical units, where possible. Where appropriate, there should be clearly defined care pathways that highlight critical points for timely and clinically appropriate transfer of careout of the acute inpatient environment.

Roles and responsibilities for transfer of care are clearly understood and communicated within a health service.

There should be ahealth-service-wide transfer of care policy accompanied by local protocols that define staff roles and responsibilities for transfer of care.There should also be clear, documented lines of accountability for decision making about a patient’s transfer of care.All staff should assume an appropriate level of responsibility for effective transfer of care from the acute inpatient environment.

Transfer of care is coordinated and communicated across all relevant healthcare providers and community support services.

Transfer of care should be coordinated and communicated across relevant teams within the health service and between the acute hospital, primary care providers and community support services.These entities and a GP should work in partnership to share the care of patients with complex and chronic conditions.There should be effective information and communication technology (ICT) infrastructure and protocols in place to support timely transfer of information between the acute hospital, primary care providers and community support services.

Health services review and monitor their transfer of care performance and related aspects of service demand and capacity.

Meaningful data should routinely be collected, analysed, interpreted and reported to improve health services’ understanding of their transfer of care performance, service demand and capacity.The performance measures outlined in section 7 of this document can assist health services to measure their transfer of care performance. Tailored information on transfer of care performance should be disseminated and discussed with relevant staff.Where transfer of care performance deviates from an acceptable level, an appropriate response should be enacted.

Planning for transfer of care

Key requirements

Preparation for transfer of care is to begin prior to a planned admission and as soon as possible for emergency or unplanned patients.
Allpatients are to undergo a thorough discharge risk assessment within 24 hours of admission.
An estimated date of transfer of care should be established prior to, or as soon as possible after, an acute patient’s admission and reviewed and updated to ensure accuracy and predictability.
All patients are to have an individualised discharge plan or transfer of care plan.
Responsibility for coordinating and implementing a patient’s discharge or transfer of care plan is to be allocated to a specific individual or team.
The individual or team responsible for coordinating the patient’s discharge or transfer of care should engage with the patient and their carer to prepare them for discharge/transfer of care.

Implementation guidelines

Conducting a discharge risk assessment

As part of the admission process, a dischargerisk assessment should be completed. The risk assessment can begin prior to admission for planned patients or at the time of admission for unplanned patients. To ensure comprehensive planning can occur and appropriate services can be arranged to support discharge, discharge risk assessments must be effective in identifying patients with more complex needs or at risk of an unplanned readmission. The discharge risk assessment should be reviewed and updated during the course of the admission.

A discharge risk assessment should be comprehensive and consider the patient’s physiological, psychological, social and cultural circumstances. It may address the following areas:

Is the patient likely to have self-care problems?
Does the patient live alone?
Does the patient have caring responsibilities for others?
Has the patient used community services before admission?
Has the patient had unplanned admissions to hospital in the previous six months?
Is the patient at risk of falls?
Is the patient at risk of developing a pressure injury?
Is the patient at risk of continuing functional decline?
Does the patient usually take three or more medications, and have their medications changed in the last two weeks?Does the patient understand how to administer the medications and do they have the ability and willingness to do so?
Is the patient taking large quantities of Schedule 8 medicines?

Risk assessments should include assessment of the specific needs of Aboriginal and/or Torres Strait Islander Victorians and culturally and linguistically diverse (CALD) patients.

The risk assessment should be updated if the patient’s clinical or social status changes.

Estimating a date of transfer of care

The estimated date of transfer of care (or discharge) is a prediction of the date and time that a patient will be transferred to another level of care. This could be the transfer of a patient from acute to subacute services, from one hospital to another hospital, or from hospital to care in the community or home.

Planning for transfer of care needs to be in progress early in the admission and may be supported by clinical or patient pathways. Transfer of care is confirmed and informed by the patient’s clinical status and goals of admission.

Unnecessary transfers of care should be avoided and everyone should work together to ensure patients access their definitive care early and avoid being moved around the system.

In determining the estimated date of transfer of care, the patient's ongoing need for care and services should be matched with the availability of these services at the next level of care. For example, if the patient is to be discharged home, the availability of their GP and relevant community service providers should be considered. It is important that relevant support services are organised and in place before the patient is discharged.

If services are not in place at the next level of care or if the patient’s condition deteriorates, it is appropriate to revise the estimated date of transfer of care.Changes to the estimated date of transfer of care should be recorded, along with the reason for this revision.Capturing and analysing data on delays to transfer of careor discharge can identify constraints in the system.

The estimated date of transfer of care should be included on patient journey boards and displayed at the bedside. This will ensure that all staff involved in the patient’s care are working towards the estimated date of transfer of care. The estimated date of transfer of care should also be clearly communicated to the patient and their carer.

Developing an individualised transfer of care plan

All patients are to have an individualised discharge plan or transfer of care plan. This plan should:

be informed by, and include, relevant information from the patient’s risk assessment, family and/or carer, GP and relevant community providers
include the estimated date of transfer of care(or discharge) and strategies to ensure the estimated date of transfer of care is met (such as communication plans with community providers, families and/or carers)
include information about referrals to hospital-based services and/or community services
include information about the patient’s transport arrangements from hospital to their transfer of care location
include information about the patient’s medications and how these will be transferred
form an integral part of the patient’s clinical notes while they are admitted
be updated as required
be provided to the patient and/or carer.

Allocating transfer of care responsibility to an individual or team

The person or team responsible for coordinating and implementing a patient’s transfer of care plan will differ depending on the patient and the health service. It may be appropriate to employ a multidisciplinary team approach where medical, allied health, nursing and other relevant staff work together through coordinated ward rounds or meetings. An agreed process of communication should be established between the patient and/or carer and the transfer of care team. A key contact for the transfer of care team should also be nominated.Alternatively, it may be appropriate to appoint a single patient treatment coordinator[3]to be responsible for coordinating the patient’s transfer of care.

Implementing the transfer of care plan

Key requirements

The transfer of care plan is to be developed and implemented in consultation with patients, their families and/or carers.
All aspects of the transfer of care plan should be understood by the patient, their families and/or carers.
A transfer of care summary should be commenced as soon as possible and developed throughout the patient’s admission.
A transfer of care checklist (or equivalent) should be completed for all patients prior to discharge or transfer of care.
The transfer of patient information must comply with the privacy principles as defined in the Information Privacy Act 2000and the Health Records Act 2001.
Patients at higher risk of readmission should be identified and strategies to minimise the risk of readmission implemented.
The Victorian Quality Council’s Inter-hospital transfer patient transfer form[4] should be used when transferring a patient from one hospital to another.
Referrals to appropriate healthcare providers and/or community support services are to be made on completion of the risk assessment.
Necessary community support services are to be engaged upon a patient’s discharge home.
Continuity of medication management should be maintained.
An appropriate discharge or transfer of care destination should be confirmed.

Implementation guidelines

Communicating with the patient, their family and/or carer

When planning for discharge or transfer of care, information should be communicated regularly to the patient, their family and/or carer. An effective communication strategy between the health service, the patient, their family and/or carer can avoid unnecessary readmissions to a health service and improve health outcomes and the patient’s experience.

The staff responsible for the patient’s transfer of care should implement the transfer of care plan in consultation with the patient, their family and/or carer. The communication strategy may include coordinating family meetings at key points in the patient’s journey. Hospital staff should ensure the patient, family and/or carer understand the information given to them.

Completing a transfer of care checklist

A transfer of care checklist (or equivalent) should be completed to ensure all appropriate activities have been carried out before the patient is discharged or transferred. This checklist may vary between health services depending on local circumstances.

Identifying patients at higher risk of readmission

Health services are encouraged to select a model for assessing readmission risk that is most appropriate for their patient population, and isinformed by available data.Systems and processesshould be in place to monitor the rates of preventable hospital re-presentation and readmission.Focused improvement work may reduce the rate of preventable readmission in high-risk patient populations.

Transferring the patient to another hospital

Inter-hospital patient transfer involves moving a patient from one hospital to another. It also involves transferring information and professional responsibility and accountability for patient care between individuals and teams within the overall system of care.

The Victorian Quality Council’sInter-hospital transfer patient transferform is designed to ensure pertinent and accurate patient information is exchanged between the referring and receiving facility and the transport provider. It is intended for use in transfers between acute health services and may be used in transfers between hospitals and other facilities such as rehabilitation centres and aged care facilities.

A clinical handover tool such as ISBAR (identify, situation, background, assessment and recommendation) should be used to facilitate the handover process.

The receiving health service should advise the referring health service that the referral has been received.

Referring the patient to healthcare providers and community support services

Implementing the transfer of care plan may involve referring the patient to:

hospital-based services such asindividual allied health services, subacute assessment and treatment services, an agedcare assessment service (ACAS)(to identify ongoing care needs) or ahealth independence program (HIP)
home-based services provided by the hospitalsuch as Hospital in the Home (HITH)
communityhealth servicessuch as the Royal District Nursing Service (RDNS), Home and Community Care (HACC) or maternal and child health services.

Patients at risk of falls should be referred to appropriate services, where available, as part of the transfer of care process.

Patients with a high risk of developing pressure injuries must have a comprehensive skin inspection conducted prior to transfer.

There must be a process in place for communicating a patient’s infectious status whenever responsibility for care is transferred between service providers or facilities.

It is important that referrals are generated in a timely manner so that services can be engaged upon the patient’s discharge home.The referral content should be comprehensive and relevant to its recipient.It should be updated during the patient’s admission to reflect changes to their condition and care needs on transfer of care.

It is expected that there is a patient identification system in place that requires at least three approved patient identifiers whenever a clinical handover or patient transfer occurs, or whenever transfer of care documentation is generated.

Note that privacy legislation stipulates that referrals cannot be directly transferred from one health service to another without the consent of the patient.